Oral surgery block 1 Flashcards
What instruments are needed for suturing
Tissue forceps – for manipulating tissue. Held in pen grip in non-dominant hand
Needle holders – for holding the suture needle. Thumb and 4th finger in rings, use index finger to support the shaft
Scissors – for cutting the suture
Suture – larger the number, the smaller the suture diameter. Suture needle with inside cutting edge to help pass through the tissue.
Key steps in doing a suture
-Needle is passed through tissue at 90 degrees to the tissue surface. At least 3mm from wound edge. Needle then passed through the other side of wound. Pull all the way through so only a little tail left on one side.
-Tie a surgeon’s knot by wrapping the suture round the needle holders twice. The needle holders go on the inside of the “valley”. The free end of the suture is then grasped by the needle holders, and the knot is slid down towards the wound. Put the little tail on the opposite side to what it was.
-It will need a few more knots to secure (depends on the type of suture).
-Too tight may cause tissue necrosis, too loose may prevent wound healing. When doing multiple sutures, make sure the knots are placed at the same side of the wound. Cut excess suture. Dispose of the needle in sharps bin
What are the 3 stages of haemostasis
- Vasoconstriction: reduces blood flow
- Platelet aggregation and adhesion- platelet plug forms within a 5-10 minutes to stop further blood loss and protect the wound from contamination. But it is unstable and easily dislodged. Dead as no blood supply
- Clotting cascade to produce fibrin- fibrin is incorporated into and around the plug to strengthen and stabalise the clot. It takes about 24 hours to form a mature clot
3 functions of a clot
- Arrest haemorrhage
- Protect the wound from contamination
- Provide substrate for further healing to take place
What is done/ not done to help form the clot and keep it in
To help form a clot= compress the socket with gauze for 5-10 mins
To help keep the clot = no smoking, no vigorous exercise for 24 hrs (increases BP), no rinsing for 24 hours (salt water after this), gentle cleaning around the area, no aspirin (anti-platelet), avoid oral contraceptive pill, avoid alcohol (vasodilation), avoid eating whilst numb
What is granular tissue. When and how is it formed. Is it dead or alive
-The fate of the clot is to be replaced by granulation tissue, which is rich in blood supply and fibrous tissue
-The blood supply migrates from surrounding tissue (i.e. bone and gingivae) whilst dead cells are removed by macrophages.
-It takes 5-10 days to establish mature granulation tissue.
-function of granular tissue= continue protective function, allow further repair to occur, establish ideal vascular bed for epithelial coverage to advance from edges of wound
-has rich blood supply so a living tissue
What is epithelialisation and keratinisation, when it occurs
-migration of epithelium occurs very quickly once blood supply is present (granulation tissue)
-takes around 2-3 weeks after extraction
-Epithelial coverage of wound re-establishes the integrity of the host. Initially it is only very thin, so easily damaged. The wound may still appear red.
-The Epithelium will eventually start to keratinize.(6 weeks) -keratinisation is the thickening of epithelium to protect itself from trauma
when is early osteoid seen. when will cortical bone in the socket remain
-after 3 weeks
-for years, especially in the elderly
what is a dry socket and how does it present and when
-if the clot fails to form or dislodges this exposes bone and causes localised bone inflammation = alveolar osteitis. It is not an infection, so no antibiotics
-usually 2-5 days after extraction.
-the patient will have felt reduced pain following tooth extraction, but dry socket pain may be described as worse than the initial toothache.
-The patient may not be able to prevent food or debris entering the socket once the clot is lost and the stimulation of the exposed bone results in frequent bursts of acute pain.
-hallitosis, bad taste
-The surrounding areas may be touched without eliciting the pain, but contact with the exposed bone will result in pain.
Incidence and causes of a dry socket. Risk factors
Incidence - approximately 1-5% of all extractions, but up to 38% of mandibular 3rd molar extractions (due to poor blood supply).
Causes- Traumatic/ difficult extractions are more likely to result in a dry socket. This may be due to more local damage to the alveolar bone in the socket. Smoking has a vasoconstrictive effect, and the sucking action when drawing a cigarette may increase risk of loss of the clot.
A compromised immune system, bleeding disorders, oral contraceptivr pill
mandibular 8 most common tooth
Management of a dry socket
-Irrigation to remove debris, food, plaque. With or without local anaesthesia with saline (first choice) or CHX 0.2% (anti-bacterial, but avoided in allergic patients, or those patients with allergic tendencies)
-A dressing to cover the exposed bone-Alveogyl which is a resorbable dressing containing Iodoform (antimicrobial), Eugenol and Butamben (anaesthetic).
[ Alvogyl is discontinued due to iodine]
-advice analgesics
What is pericoronitis, causes and risk factors. Who is more likely to get it
What it is= swelling and infection in the gingiva or operculum overlying the molars/ wisdom teeth
Causes= Bacteria, food debris and plaque accumulates under and around the tissue, causing inflammation.
Risk factors= partially impacted, poor oral hygiene, excess gum tissue, stress, pregnancy.
common in partially impacted molars. More common in lower than upper. Common ages 20-29,
Pericoronitis symptoms, complications, management and prevention
-Signs and symptoms= severe pain, swollen and red tissue, pain when swallowing, discharge of pus, trismus, pain when biting, loss of appetite. Chronic can include bad breath, bad taste, achy pain, fever
-Complications= Ludwig’s angina – infection spread to floor of mouth in the glands and nodes and neck and head. Or Sepsis -systemic infection in blood
-Management= cleaning the tissue (CHX or saline irrigation with syringe). If systemic antibiotics (metranidazole). Having the flap/ operculum removed, extraction (only if multiple flare ups or unrestorable tooth) . At home use painkillers, warm salt-water rinses.
-Prevention= good oral hygiene
Defintion of analgesia and anaesthetic. Which is LA classed as
Anaesthesia = loss of perception of pain, touch, pressure, temperature, motor function
Analgesia = loss of perception of pain
LA = sits between these. no pain, light touch or temperature. Still feel pressure and motor function
Describe what nerves innervate the pulp/ palatal/ buccal tissues of maxillary 1, 2 and 3
1and 2= anterior superior alveolar nerve (of CNV2) for pulp and buccal. Nasopalatine nerve for palatal
3= same but greater palatine nerve for palatal
Describe innervation of pulp/ buccal/ palatal of maxillary 4-8
4 and 5 = middle superior alveolar nerve for pulp and buccal. Palatal is greater palatine
6-8= posterior superior alveolar nerve for pulp and buccal. Greater palatine
Describe innervation of mandibular pulp/ buccal/ lingual for 1-3
pulp= inferior alveolar nerve (incisive branch)
lingual= lingual nerve
buccal= mental nerve of IAN
Describe innervation of mandibular pulp/ buccal/ lingual for all teeth
-Lingual= lingual nerve
-Pulp= IAN. 1-3=incisive branch of IAN
-Buccal 6-8= long buccal nerve. 1-5= mental nerve
What is Ringer’s solution
Contained in LA solution and acts as the solvent
What is a vasoconstrictor used for in LA. What prevents it breaking down
causes constriction of vessels to prolong the actions, reduce operative haemorrhage and reduce systemic effects
-a reducing agent prevents the vasoconstrictor breaking down
Faults that occur in/on a cartridge that would need throwing out
-Passed expiry date, cloudy solution, unreadable, glass fractured, large air bubble
What LA info is required in patient notes
Drug name, concentration and adrenaline, amount used, technique/ site, batch number, expiry date, aspiration positive or negative
What needle lengths and gauge sizes are there
10/25/35mm
27 or 30 gauge
When to avoid LA with adrenaline and when to reduce
Reduce or avoid adrenaline dose if CVD, drug interactions, compromised blood supply. But if no adrenaline, then LA less likely to work so heart could be affected when patient feels lots of pain
-reduce to 2-3 cartridges if tricyclic antidepressants, cardiac beta blockers, diuretics.
-avoid recreational drugs for 24 hours
Ways to reduce discomfort during injection
-Topical anaesthesia (works within 30-60s)
-Stretch tissues (retract tissue with finger or mirror)
-Distract patients
-Sharp needle
-Position supraperiosteally (if hit bone, withdraw needle 2mm so not under PDL)
-Aspirate
-Inject slowly (1ml over 30s)
How much do you inject for an IDB and infiltrations
-up to thick line for IDB and buccal infiltrations (1.5ml)
-width of the rubber thing for palatal infiltrations (0.2ml)
-lingual infiltrations= 0.5ml
Onset and duration Time of buccal infiltration
Onset 2 mins, duration 45 mins
Where to inject palatal infiltrations, incisive nerve block, and greater palatine nerve block
1-Palatal infiltrations = Halfway between midline of palate and gingival margin, and then slightly distal to tooth (except 8s as would miss greater palatine foramen so inject mesial)
2-Incisive nerve block= side of incisive papilla at incisive foramen to anaesthetise nasopalatine nerve
3-Greater palatine nerve block= at greater palatine foramen, between 2nd and 3rd molars
IDB landmarks, onset time, duration time, needle used, how much to inject. What to do if need lingual
-use long 35mm, 27 gauge needle. Lidocaine
-onset 5-8 mins, duration 1 hour
-Palpate internal oblique ridge then pull thumb into coronoid notch
-Insert in the middle of the pterygomandibular depression, lateral to the raphe (connects the buccinator and superior pharyngeal conctrictor).
-Insert it ¾ from tip of thumb to raphe
-Use the opposite premolars as a guide for the angulation
-Needle hits bone at 25mm (so don’t use short needle!) 1cm of needle should be remaining. You want to be supraperiosteal so withdraw needle a couple mm once you hit bone.
-Aspirate then inject 1.5ml.
-Adding a lingual block- once injected the IAN, withdraw the needle halfway, inject most of the remainder at that site, and continue to inject as you withdraw. [The lingual nerve is not as deep, it is halfway between the IAN and raphe]
Where you inject the long buccal block and how much to inject
inject 0.5ml
-1cm up and out from 3rd mandibular molar
-in coronoid notch
Where to inject for mental block, and how much
inject 1.5ml
-inject at mental Forman, between the premolars
How LA stops pain.
LA binds to sodium channels on nerve membranes so no depolarisation can occur and no message is sent from the nerve to the brain so no pain is felt
Why infiltrations not used on lower teeth
Can be done in the maxilla because the bone is relatively porous so LA can penetrate more easily and cause action to the nerve. Mandible has a thick layer of cortical bone so less porous for the LA so blocks are used.
How intraligamentary injections work (where, how much, onset, duration) Why it doesn’t work as well with on mandibular incisors
-inject into PDL, requires high force
-30 gauge 10mm needle
-mesio-buccal aspect of root at 30 degrees. Advance needle down PDL to max penetration. Inject 0.2ml at each root slowly (30s) Wait 10s before withdrawing needle to prevent LA pouring out. Small dose needed, rapid onset, short-acting (15mins), uncomfortable, possible systemic effects, possible tissue damage
-BUT doesn’t work as well on mandibular incisors as perforations between PDL and bone not as good,
% and how much adrenaline of lidocaine and articaine
2% lidocaine with 1:80,000 adrnaline
4% articaine with 1:100,000 adrenaline
Reasons for extraction
- Acute apical abscess. Infection. Swelling
- Pericoronitis- multiple episodes
- Periodontal disease. Bone loss. Mobile teeth
- Trauma to teeth or jaws
- Orthodontic. Overcrowding. Retained deciduous. Supernumerary. Balancing extractions
- Involved in cysts or tumours.
- Prophylaxis
the 3 principles of extraction
- Expansion of bony socket
- Disruption of periodontal membrane
- Removal of tooth
What forces are required for each tooth
-Upper molars and premolars = apical and buccal force
-Lower molars = apical and buccal, and sometimes figure of H rotation
-Lower premolars, canines and upper incisors –=apical and rotation
-Lower incisors = apical and buccal force
Function of luxators. What type of elevator do they look like
Moves bone away from tooth. Widen the socket and sever the PDL. Help to create an application point. Similar to couplands elevator but lighter and sharper. Never luxate lingually or palatal or anywhere close the mental foramen
Complications with extractions (pre, during, post)
-Pre-extraction: allergic reaction, failure of LA
-During: wrong tooth, fractured crown/ roots/ bone. Inhaled or ingested. Damage to other teeth, TMJ, soft tissue, or antrum of maxillary sinus
-Post-extraction: haemorrhage, infection, dry socket, bone sequestration, osteonecrosis, osteomyelitis, OAC/ OAF
What is bone sequestration
small fragments of bone can break away. It is the body’s way of removing extra bone from tooth extraction site
What is osteonecrosis
dead bone. Due to an underlying medical condition (radiotherapy, bisphosphonates)
What is osteomyelitis
deep bone infection. Rare. Arises due to immunosuppression
What is oroantral fistula (OAF) Management
-an epithelialized ororoantral communication (OAC). -abnormal connection between the oral and antrum of maxillary sinus. Usually created when maxillary tooth closely related to the sinus is extracted. Air/ fluid can spread and cause infection.
-Breathing through nose causes air to travel to mouth. Coughing up blood
-Small OAC may heal spontaneously and patients advised not to blow nose or sneeze with mouth closed for next 2 weeks. No sucking straws or sweets
-Splints or immediate dentures can be worn to apply pressure to prevent fluid passage.
-amoxicillin, CHX 0.2%, ephedrine 0.5% nose drops
-But if larger it would require surgical closure to prevent chronic sinusitis.
Examples of reasons for mucoperiosteal flaps. Reasons for surgical extractions
-draining abscess
-fractures
-corrective jaw surgery
-pre-prosthetic surgery
-bone grafting, implant removal, guided bone regeneration
-surgical debridement, connective tissue graft (perio surgery)
-surgical crown lengthening
-endo surgery (apicectomy)
-access to cysts or tumors
-cleft lip/ palate
-surgical extractions=fractured teeth, divergent roots, impacted teeth, ectopic teeth, retained roots
What 4 layers do you cut through when incising mucosa, all the way down to bone
epithelium, lamina propria (papillary and dense layer), submucosa, periosteum
describe what the lamina proper, submucosa and periosoteum is
-Lamina propria – Immediately below epithelium, collagen and elastin. contains vascular and neural structures.
-Submucosa – Connective tissue, contains vascular and neural structures (Not present in the keratinised mucosa)
-Periosteum – Thin inflexible layer lining bone
what 2 layers make up mucosa
lamina propria and epithelium makes up mucosa.
the 2 principles of flap design
-Adequate access – Consider the size of the flap and number of sides (2, or 3). Must be large enough to visualize the whole surgical site. Usually expose 1/3 of the root to be removed
-Allow healing – Blood supply in the mandible comes (broadly) from an inferior and posterior direction, in the maxilla this is superior and posterior. Ensure the flap base is wider than apex to allow adequate blood supply to the tip of the flap.
5 main steps of surgical tooth removal. Instruments involved
- Raise mucoperiosoteal flap: scalpel to incise, Warwick James elevator, Howarths periostea elevator to elevate flap, retracted with Bowdler Henry rake retractor
- Bone removal: use Rosehead bur
- Division of tooth for multi-rooted teeth: fissure bur initially then couplings to propagate the facture
- Tooth removal: elevators or forceps
- Debride and Suturing: smoothen sharp edges of bone with bur, remove debris, saline irigation.
Reasons for bone removal in surgical extraction
to reveal the tooth, to provide a point of application for an elevator, to provide access to a furcation of a tooth prior to sectioning, to relieve an impaction
What suture material is used, how long it take to resorb
-vicryl
-4-6 weeks to resorb (realistically few weeks)
Body changes that occur in pregnancy (physical, CVS, RS, GI, renal, hormones)
-increased fetal growth and uterus
-increased CO, SV, HR, metabolic demands
-compression of IVC, reducing venous return to heart
-blood volume proportionally larger than RBC so physiological anaemia
-diaphragm pushed up 3-4cm so reduced functional residual capacity and increased thoracic pressure
-increased progesterone - increases respiratory rate
-increased intragastric pressure, food moves slowly into stomach, delayed emptying
-relaxation of lower oesophageal sphincter= heartburn, vomitting
-increased glomerular filtration
How treatment is affected for pregnant patients
-left lateral lying position with right hip elevated by 15 degrees as supine position:
compresses IVC causing supine hypotension syndrome, compresses lungs, causes indigestion
-GA risky as risk of inhalation of vomit
-morning appointment avoided as sickness
-increased GFR means increased renal clearance so need to increase drug doses
Oral changes that occur due to pregnancy
-Gingivitis can be caused due to estrogen and progesterone increasing blood flow to your gums, and this makes them more sensitive to irritants.
-Gingival hyperplasia are benign growths which are also linked to pregnancy, along with pyogenic granulomas which is due to increased hormone levels and plaque.
-Pregnant patients may also have an increased caries risk due to reduced saliva, increased snacking and vomiting. Tooth erosion
What is the major risk if don’t hit bone during IAN
hitting facial nerve and causing facial paralysis
what is a couplands, Warwick James and cryers and cowhorn best used for
-couplands= mandibular molar
-warwick James= upper 8
-cryers and cowhorn= furcation
How much to inject for IDB, buccal, palate, lingual, long buccal, mental block, intra-ligamentary, intra-osseous
-Intra-osseous= 0.7 -1.0mm
-Buccal -1.0 - 1.5ml
-Palatal-0.2ml
-Lingual-0.5ml
-Long buccal -0.5ml at coronoid notch
-Mental block- 1.5ml, between 4 and 5
-Intra-ligamentary= 30 gauge, 30 degree approach, 0.2ml per 30s
-IDB- 1.5ml
What is trismus. Causes. Signs. Management
-muscle spasm causing difficulty and painful opening mouth
-usually should open in 35mm (2 fingers width)
-causes are TMJ dysfunction, head and neck radiotherapy, impacted third molar, after wisdom teeth removal, Inflammatory conditions (rheumatoid arthritis, osteoarthritis and scleroderma) Removal of tonsils. Jaw nerve damage. Tetanus. Muscle atrophy. Poor oral hygiene. Myostitis
1. Massage (gently rub) your jaw muscles.
2. Exercise your jaw muscles.
3. Keep good posture.
4. Keep good oral hygiene.
5. Eat soft foods
6. Heat
Patients will complain of bad breath, unable to eat, unable to get dentures in, unable to brush, struggle speaking. Advise single tufted tooth brush
explain incisional, excision, punch, core, fine needle aspirate, brush biopsies
-Incisional biopsy = A small cut is made into the area to be examined and a small piece is removed. Most common for mouth lesions (e.g. ulcers).
-Excisional biopsy = Surgical removal of a tumour and some normal tissue around it
-Punch biopsy = Small, tube-shaped piece of skin and some other tissue underneath are removed using a sharp cutting tool. Can be done anywhere on the body
-Core biopsy = Needle is passed through the skin to take a sample of tissue from a mass or lump. Most commonly used to sample breast tissue.
-Fine needle aspiration biopsy = Thin needle is inserted into an area of abnormal-appearing tissue or body fluid.
-Brush biopsy = Small brush that is used to scrape samples of a suspicious spot or sore. Not very accurate at giving a diagnosis.
Reasons for coronectomy. Disadvantages
-crown removed to limit damage to IAN if close proximity. then sutured
-risk of infection from the roots. Migration of the retained root. Root may become mobile during coronecotomy which would need to be extracted
